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Based on a review of policies and procedures and staff interviews, the hospital failed to ensure the process for submitting a grievance was clearly defined for the patient.

Findings:

1. The hospital "welcome packet" states in the category "grievance procedure" Patient complaints or concerns should be reported in writing using a grievance form. These forms can be obtained from any staff member. Complete the form and place it in the locked grievance box on the unit. Grievance forms are collected each business day and processed within 3 working days". There is no policy addressing submitting a verbal grievance.


2. The "welcome packet" also contains reporting agency addresses and telephone numbers. The hospital failed to identify what the contact information was for.

Based on review of the hospital's grievance/complaint policy, grievance log and four grievances and interviews with hospital staff, the hospital failed to follow its complaint policy for investigating complaints. This occurred for four of four grievances (Grievance #1 through 4) reviewed.

Findings:

1. The hospital "welcome packet" states in the category "grievance procedure" Patient complaints or concerns would be investigated and the complainant would receive a written response containing the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.

2. On 05/10/2011 at 1616, the Patient Advocate, the person identified as responsible for the grievance process, stated she only talked to the patient/complainant and then "passes" information to the responsible party/department head. She stated she does not interview staff and does not sit on the grievance committee either.

3. The surveyors asked for all the data and supporting documents concerning Grievances #1, 2, 3, and 4. Data provided did not contain evidence the complaints had been investigated and a written response of the conclusion, with the required information, provided to the complainant. The surveyors asked for any addition information that showed investigation. None was provided.

4. The date on the written response was either the date the Patient Advocate talked with the patient and told them the Director of Nursing would interview staff involved or the date before and only said the patient's concern would be referred to the Director of Nursing or Administration.

5. These findings were reviewed with administrative staff on the afternoon of 05/10/2011.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. The hospital failed to investigate, taken action or have a method to identify incidents or patterns to protect patients.

Findings:

1. The hospital did not have policies and procedures in place to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. Patient #1's record indicated the patient was admitted 1/16/11 and transferred emergently to a local hospital on 1/29/11. According to the nursing assessment 1/16/11 the patient was ambulatory. In the nursing assessment section labeled ENT (ear, nose, throat) a check mark was placed by "patient denies". In the section labeled CV (cardiovascular) a check mark was placed by "patient denies". In the section labeled RESP (respiratory) a check mark was placed by "patient denies". After the initial assessment and history and physical, there was no documentation assessing medical issues by nursing, mid-level practitioners, or physicians. The record indicates the patient was transferred emergently. An order by PA#J stipulates patient transferred emergently secondary to dehydration. There was no documentation by PA-# J regarding the transfer or indications for transfer. There was no lab work completed on 1/29/11 indicating the patient was dehydrated. Progress notes by Physician K did not include medical findings or indicate any changes in medical throughout the stay. According to the transfer sheet, documentation in a narrative portion by Staff L states "pt (patient) non responsive unable to feed or give fluids. Pt very lethargic-non responsive having loose stools, large soft stool just prior to sending. Pt has not had any medications in the past two days. Pt non responsive".

In an interview on 5/10/11, Staff B told surveyors the facility was told by the receiving facility the patient had a medical diagnosis of pneumonia on transfer. Staff B stated he was not sure why PA # documented "dehydration" in the transfer order.

Multiple emergent transfers were identified in hospital documents from January 2011-March 2011. Review of January, February, and March 2011 Quality Council meeting minutes, did not show evidence emergency transfers for medical care were reviewed, analyzed or acted on to improve performance.

3. Patient #1 had orders at the time of transfer were for Tricor 145mg (milligrams) po (by mouth) q d (every day), Simbastatin 40 mg po q d, Fluoxetine 40 mg q d, Keppra 750 mg po BID (twice daily), Depakote ER 1500 mg po at HS (bedtime), Clozapine 100 mg po TID (three times a day) hold Clozapine if sedated. Documentation in the patients chart indicated the patient did not receive any meds on 1/28/11 or 1/29/11. There were no orders to hold meds other than Clozapine.

The policy "medication administration" stipulates in section 22. Medication Variance Reports must be completed by the licensed staff who identifies the variance for all the following: any variation of protocol from medication policies, omission, ". Review of incidents did not indicate the omission of Patient #1's medications for two days was reported as a variance.

Review of January, February, and March 2011 Quality Council meeting minutes, pharmacy reports did not document medication variance reports were reviewed, analyzed or acted on to improve performance in medication management.

4. Review of personnel files (Staff C,D,E,F,G) did not have evidence of current CAPE (Creating a Positive Environment) training. One (E) of three registered nurses (C,D,E) did not have a current license or verifcation of valid license. Staff Ewas documented as providing care in Patient #1's chart.

4. The above findings were reviewed with administration during an exit conference. No further documentation was provided.

Based on the review of abuse and neglect policies and procedures, a written letter from a hospital staff member, patient complaints/grievances and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describes the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

1. The hospital provided policies for review. The policy states staff will be trained to identify posible victims of abuse (physical assault, rape, sexual molestation, domestic abuse, elder neglect or abuse and child neglect or abuse. The proper procedure for reporting suspected abuse will be included in orientation. The policy further stipulates "any staff member who witnesses or suspects staff to patient abuse is responsible to immediately report to their supervisor". The policy did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. Patient #3 reported to staff allegations of sexual abuse by a staff member(Staff G). Hospital documents did not indicate a complete investigation was performed. The facility did not identify the allegation as a grievance. Hospital documents indicated patient #3 told staff she was afraid to say anything and did not want the police called. Patient #3 told staff that staff F's brother was with the local police and was fearful of retaliation. Patient# 3 also told staff that staff F told her "not to tell". The investigation did not include any evidence the facility discussed these allegations with staff F and why the patient would know/state this information. Staff A, B, and I (patient advocate) told surveyors this type of information was not appropriate to be shared between patient and staff. One statement taken from one of Patient 3's roommates indicated the roommate thought something was going on between the staff #3 and the patient. Staff B told surveyors videotape of the incidents were inconclusive. Staff B told surveyors in an interview on the afternoon of 5/10/11, the patient's physician had stated the patient may have been fabricating the incident. The investigation documents provided to surveyors did not include any information from the physician or the therapist. The above was discussed with administration and no further documentation was provided.

Based on review of medical records,and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) supervised the nursing care for each patient. The supervisory nurse failed to ensure physicians' orders and hospital policies were followed. This occurred in two of four patient charts (Patients #1 and 2).

Findings:

1. According to the hospital policy Nursing Assessment/Reassessments, a continuous evaluation of patient needs and nursing interventions to meet those needs with appropriate documentation in the Nurse's Notes is the expectation for all nursing staff. Further in the policy, it stipulates. physical limitations/restrictions will be identified by patient and/or nurse and reported to the attending pysician for patient specific orders. The policy also stipulates all staff members are expected to report and document any signs of change in the patient's condition to the RN: changes in vital signs, changes in level of consciousness, changes in behavior, changes in physical abilities, suspected side effects of medications. The RN is responsible to document and report the observed changes to the attending physician or physician on-call.

2. Patient #1 - The patient, an 25 year old, was admitted on 01/16/11 for assessment and evaluation of aggressive behavior and medication stabilization with possible long term care placement. On admission the nursing assessment the patient was ambulatory. In the nursing assessment section labeled ENT (ear, nose, throat) a check mark was placed by "patient denies". In the section labeled CV (cardiovascular) a check mark was placed by "patient denies". In the section labeled RESP (respiratory) a check mark was placed by "patient denies". After the initial assessment and history and physical, there was no documentation assessing medical issues by nursing, mid-level practitioners, or physicians. There was no documentation indicating the nurse notified the physician or mid-level the patient began using a wheelchair to move around the unit two days prior to discharge. There was no documentation indicating the nurse notified the physician all the patient's medications were held for the last two days of stay.

According to the transfer sheet, documentation in a narrative portion by Staff L states "pt (patient) non responsive unable to feed or give fluids. Pt very lethargic-non responsive having loose stools, large soft stool just prior to sending. Pt has not had any medications in the past two days. Pt non responsive". On 1/29/11 documentation prior to transfer did not indicate the patient had an altered level of consciousness. There was no documentation the physician was notified on 1/26/11 (two days prior to transfer) a change in patient condition had occurred. There was no documentation the patient had not eaten or was unable to take fluids. The RN failed to ensure physician orders and hospital policies were followed.


3. Patient #2 - The patient, a 62 year old admitted to the geropsychiatric for aggression and medication adjustment was admitted 1/26/11.. On admission, the physician ordered multiple medications to be given daily. On 1/27/11 none of the medications ordered for the patient were administered. There was no order to hold or discontinue the medications. The RN did not supervise the nursing care to ensure medications were administered as ordered.

4. The findings were reviewed with administration at the exit conference. No further documentation was provided.

Based on review of patient medical records and an interview with hospital staff, the hospital failed to ensure medication were administered according to physician's orders. In one of four (Record #1,2,3,4,) medical records reviewed, medications were held without a physician's order.

Findings:

1. Record #1 - The patient, a 25 year old, admitted on 1/16/11 and transferred to an acute care facility on 1/29/11, had orders at the time of transfer for Tricor 145mg (milligrams) po (by mouth) q d (every day), Simbastatin 40 mg po q d, Fluoxetine 40 mg q d, Keppra 750 mg po BID (twice daily), Depakote ER 1500 mg po at HS (bedtime), Clozapine 100 mg po TID (three times a day) hold Clozapine if sedated. Documentation in the patients chart indicated the patient did not receive any meds on 1/28/11 or 1/29/11. There were no orders to hold meds other than Clozapine.

2. Record #2 - The patient, a 62 year old admitted to the geropsychiatric for aggression and medication adjustment was admitted 1/26/11. On admission, the physician ordered multiple medications to be given daily. On 1/27/11 none of the medications ordered for the patient were administered. There was no order to hold or discontinue the medications.

3. The policy "medication administration" stipulates in section 22. Medication Variance Reports must be completed by the licensed staff who identifies the variance for all the following: any variation of protocol from medication policies, omission, ". Review of incidents did not indicate the omission of Patient #1's medications for two days was reported as a variance.

4. Review of January, February, and March 2011 Quality Council meeting minutes, pharmacy reports did not document medication variance reports were reviewed, analyzed or acted on to improve performance in medication management.

5. The above findings were reviewed with administration in an exit conference. No further information was provided.

Based on record review and interviews with hospital staff, the hospital does not have a system to report medication errors and adverse drug reactions and to analyze these to identify and implement potential corrective actions through the hospital-wide quality assurance program.

Findings:

1. Meeting minutes reviewed for 2011 did not document that a pharmacist was reviewing medication incidents and analyzing data for trends to improve medication management and implement corrective action.

2. This finding was reviewed with administration in the exit conference. No further documentation was provided.